"Irrational" factors may drive end of life access to radiation

NEW YORK (Reuters Health) - Access to radiation treatments to ease cancer symptoms in the last days of life may be driven by costs and other non-medical considerations, a new U.S. study concludes.

Researchers looking at Medicare claims over nearly a decade found that only a small proportion of cancer patients received radiation in their final 30 days of life, but of those who did get the treatment - typically used to ease pain and other symptoms in the terminal stages of the disease - one in five got more than the recommended number of doses.

"The use of radiation itself was low, what was high was the percentage of patients who were getting 10 days or more," said Dr. Ashleigh Guadagnolo of the MD Anderson Cancer Center at the University of Texas, who led the study.

Guadagnolo declined to comment on whether the number of treatments was appropriate, but one cancer expert said that the study showed wasteful, irrational thinking behind some radiation therapy.

Dr. Otis Brawley, chief medical officer of the American Cancer Society, said that while radiation therapy for palliative care is reasonable, 10 or more treatments for patients during the last month of life is a "waste of resources."

The conundrum, Brawley told Reuters Health, was that patients who received radiation got too much, but that too many patients who could have benefited from radiation got no therapy.

"This study shows there's a lot of irrationality in how we treat patients," said Brawley, who was not involved in the new work.

Doctors use radiation not only to blast away cancer cells and tumors when attempting to cure cancer, but also as an alternative to steroids and pain medications to relieve bleeding and painful symptoms when cancer spreads to the bones, brain and spine.

Many previous studies have focused on the use of chemotherapy at the end of a cancer patient's life, but the new report, published Monday in the Journal of Clinical Oncology, is the first to examine how doctors use radiation with terminal patients, according to Guadagnolo's team.

The researchers were interested specifically in what factors might determine when radiation treatment is given to terminal cancer patients, and especially whether Medicare payment policies have any influence on the treatment's use.

So the researchers evaluated more than 202,000 Medicare claims for patients over age 65 who died from the five most common cancers in the U.S., including lung, breast, prostate, colorectal and pancreatic cancers between 2000 and 2007.

They assumed that most radiation treatments during a patient's final 30 days were palliative, that is, meant to treat symptoms rather than to cure the cancer.

Overall, about 15,000 patients (a little more than seven percent) received radiation therapy in the last month of life. And of those, almost 18 percent spent more than 10 of their final 30 days getting radiation treatments.

Factors that were linked to receiving 10 or more treatments included being white, not receiving hospice care and being treated in a freestanding cancer treatment facility rather than a university-associated hospital.

The costs for patients who got radiation treatment amounted to an additional $3,453 per patient, on average. However, among those who were getting hospice care and radiation, the combined costs were $2,675 less than the costs for patients who got neither radiation nor hospice care.

Medicare caps payments for patients who elect hospice care at a daily rate that's below what a radiation treatment would cost, the report points out. And a general decline in the use of radiation from 2000 to 2007 tracks with an increase in hospice use.

Besides cost, previous research has also found a variety of barriers to access in the use of radiation therapy at the end of life, including race, sex, household income, nursing home residence and travel time to a hospital, the authors note.

"The take home message for me from this study was that it's not likely the case that we're going to save money by forgoing radiation and in fact, radiation is probably a little bit underutilitzed," Dr. Stephen Lutz, a radiation specialist at the Blanchard Valley Regional Cancer Center in Ohio, told Reuters Health. Lutz was not involved in the study.

Dr. Michael Steinberg, a radiation oncologist at the David Geffen School of Medicine at UCLA, said the costs need to be put into context. Many patients in his practice don't want to be on narcotics or steroids that can cause many unpleasant side effects such as mental fogginess.

"(Narcotics and steroids) are not necessarily solutions, this is more like warehousing very old patients and something to be avoided, if you can control the pain with a short course of radiation, there is a value proposition," said Steinberg, who was not involved in the new study.

On the other hand, radiation therapy to lessen cancer symptoms has limits since its pain-reducing effects can take days as opposed to hours for narcotics, noted Dr. Stephen Gripp, a radiation oncologist at the University Hospital D�sseldorf at Heinrich-Heine-University.

Plus, there's the inconvenience factor.

"Radiotherapy (transport, positioning on the table, waiting) is annoying or even painful for terminally ill patients," Gripp told Reuters Health in an email.

In past research, radiation oncologists have examined how many treatments are appropriate for end-of-life care and found in some cases, such as bone metastasis, a single treatment is just as effective in reducing pain as multiple treatments.

However, doctors tend to be reluctant to use fewer treatments for patients who are near death, Lutz said, because they are unsure how long the patient will survive and benefit from the treatments.

In 2011, the American Society for Radiation Oncology, a trade group, published guidelines to help doctors reduce the number of treatments for patients with bone metastasis.

The study was unable to "tell why patients got radiation; nor do we have any data in this study on what benefit they received or whether it improved their quality of life," Guadagnolo told Reuters Health.

The study had other shortcomings, Steinberg noted.

"When you look at cost - why do these patients cost more to get the radiation - it's not just because of the radiation, they're typically getting a lot of other things as well," Steinberg said.

Experts said that the long-term risks for radiation therapy in terminal patients were negligible, and most patients wouldn't survive to see any longer-term side effects.

"This is more about a broken payment system than anything about radiation overdose," Steinberg concluded.